BACKGROUND VERIFICATION
CERTIFICATION BY APPLICANT (read carefully):
I hereby authorize all my employers and schools (unless otherwise noted) to release any and all information concerning
me, including information of a confidential or privileged nature. I hereby release any and all employers from any
liability or damage that may result from furnishing the information requested .
Applicant’s Signature _____________________________ Date ___________________
(TO BE COMPLETED BY HIRING MANAGER)
APPLICANT’S NAME (please print) __________________________________________
POSITION CONSIDERED FOR: ___________________________________ F/T or P/T
NAME OF REFERENCE: _______________________________ PHONE # ______________
COMPANY NAME: ______________________________ FAX #_____________
DATES OF EMPLOYMENT: __________________________
WAS APPLICANT’S RELEASE FAXED TO REFERENCE? YES ____
1. Reference refused to give any information: ______
2. What was ________ (applicant’s name) overall performance when he worked for you?
_____________________________________________________________________
3. Were there any problems, on the job, that we should know about?
________________________________________________________________________
4. Are you aware of any allegations involving patient abuse or abusive behavior?
________________________________________________________________________
5. Would you rehire? Y N
6. Other Comments: ______________________________________________________
_____________________________________________________________________
Manager’s Signature _______________________________ Date: _______________
Printed Name __________________________________________
RETURN TO HR WITH COMPLETED REQUEST TO HIRE FORM
(OVER)
Amended 3/1/11
BACKGROUND AND REFERENCE INQUIRIES:
Guidelines to Reviewing An Applicant’s Current and Past Work History
A Sample Telephone Script
After reading numerous applications and interviewing the top applicants for 30-60 minutes, how do you
know which of the finalists is the perfect candidate for your work unit? How can you find out more about
the applicants you interview? An avenue to assist you with furthering your hiring decision is calling and
checking an applicant’s previous employers.
When to Check: At a minimum, a background check of the candidate of choice is required. A hiring
manager may do a background check on other finalists if he/she believes it will assist
with making the final decision.
Whom to Call: The hiring manager must contact at least the candidate’s current* or last employer.
The hiring manager is free to contact other previous employers.
(complete another form)
Introduction**: Be sure to introduce yourself and the purpose of your call.
Sample introduction: “Hello, my name is ________. I am (title/ organization).
_________ (Candidate’s name) is applying for (title/position) job with my
Department. I am conducting a background check on ________(candidate’s name)
and would like to ask you a few questions about him/her. Is this a good time for us
to speak? Or, is there another time that is more convenient?
Closing: Sample closing: “Thank you very much for your time and the information you have
provided about __________(candidate’s name). Should you have any information
that you forgot to tell me or have questions later about our conversation, please call
me at ________________.
* Please respect the candidate’s request not to call a current employer or supervisor
** Do not be discouraged that the individual you call may not wish to respond to your inquiries
about the candidate’s current or past work performance. Get as much information as you
can and document responses (even it is “no information given by reference”) to your
inquiries.
Amended 3/1/11
